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Aetna Aetna
Clinical Policy Bulletin:
Phototherapy for Psychiatric Disorders
Number: 0370


Policy

  1. Aetna considers a high-intensity light unit for light box therapy medically necessary durable medical equipment (DME) for members who have seasonal affective disorder (SAD) and meet both of the following criteria.

    1. Member is diagnosed with bipolar disorder or recurrent major depression; and
    2. Member meets DSM-IV criteria for a seasonal mood disorder: at least 2 years of seasonal depressive episodes which completely remit when daylight increases in the spring and which substantially outnumber any non-seasonal depressive episodes.

    Aetna considers light box therapy experimental and investigational for depressive symptoms in persons with anorexia nervosa, post-natal depression, pre-menstrual syndrome, non-seasonal depression, childhood sleep disorders, sleep disorders in the elderly and in visually impaired children, sleep or behavioral disorders in dementia, and for all other indications because its effectiveness for these indications has not been established.

    Note: Light box therapy requires a high-intensity light unit (e.g., Bio-Light, Brite Lite, Dawn Simulator, etc.).  They are not the same as “Tanning Lights” that give off an entirely different band or spectrum of light.

    Note: When criteria are met, Aetna covers rental of the high-intensity light unit for the first month to see if home phototherapy is effective in relieving the member's depression.

  2. Aetna considers extra-ocular light therapy (application of phototherapy to areas of the body other than the retina) experimental and investigational for all indications including the treatment of members with SAD because its effectiveness has not been established.



Background

Seasonal affective disorder (SAD) is a seasonal form of major depression with features similar to major depressive disorder but occurring on a cyclical basis related to ambient light deprivation during winter months.  Both phototherapy and medications are frequently used (University of Michigan, 2005).  Current evidence-based guidelines on treatment of depression state that use of bright light therapy for the treatment of major depression with a seasonal specifier is well-established (ICSI, 2006; American Psychiatric Association, 2000). 

Westrin and Lam (2007) stated that clinical studies show equal effectiveness with light and anti-depressants, so patient preference should be considered in the selection of initial treatment.  Dawn stimulation, negative air ions, exercise as well as cognitive behavioral therapy are under investigation and may also be helpful treatments for SAD.

In a controlled study, Rohan et al (2007) compared SAD-tailored cognitive-behavioral therapy (CBT), light therapy (LT), and their combination to a concurrent wait-list control.  Adults (n = 61) with major depression, recurrent with seasonal pattern, were randomized to one of four 6-week conditions: (i) CBT (1.5-hour twice-weekly group therapy), (ii) LT (10,000-lux for 90-min/day with administration time individually adjusted), (iii) combined CBT + LT, or (iv) a minimal contact/delayed LT control (MCDT; LT following 6 weeks of monitoring).  Cognitive behavioral therapy, LT, and CBT + LT significantly and comparably improved depression severity relative to MCDT in intent-to-treat and completer samples.  Cognitive behavioral therapy + LT (73 %) had a significantly higher remission rate than MCDT (20 %).  Using prospectively measured summer mood status to estimate the "functional" population, CBT + LT also had a significantly larger proportion of participants with clinically significant change over treatment compared with MCDT.  The LT condition outcomes virtually replicated results from prior trials.  The authors concluded that CBT, alone or combined with LT, holds promise as an effective SAD treatment and warrants further study.

There is a lack of evidence for bright light therapy for indications other than SAD.  Systematic evidence reviews have failed to identify reliable evidence of LT for post-natal depression (Corral et al, 2000; Craig and Howard, 2008), pre-menstrual syndrome (Krasnik, 2005; Kwan and Onwude, 2006), non-seasonal depression (Arja et al, 2004), sleep disorders in children (Montgomery and Dunne, 2006), sleep disorders in the elderly (Montgomery and Dennis, 2002), and sleep or behavioral disorders in dementia (Cohen-Mansfield, 2001; Forbes et al, 2004). 

The American Psychiatric Association's Task Force reviewed the literature on individual complementary and alternative medicine (CAM) treatments for major depressive disorder (MDD), methodological considerations, and future directions for CAM in psychiatry (Freeman et al, 2010).  Individual CAM treatments were reviewed with regard to efficacy in MDD, as well as risks and benefits.  Literature searches included MEDLINE and PsycINFO reviews and manual reference searches; electronic searches were limited to English-language publications from 1965 to January 2010 (but manual searches were not restricted by language).  Treatments were selected for this review on the basis of (i) published randomized controlled trials in MDD and (ii) widespread use with important clinical safety or public health significance relevant to psychiatric practice.  Consensus was reached by group conferences.  Written iterations were drafted and sent out among group members prior to discussion, resolution of any differences of interpretation of evidence, and final approval.  A review of randomized controlled trials for commonly used CAM treatments such as omega-3 fatty acids, St John's wort (Hypericum), folate, S-adenosyl-L-methionine (SAMe), acupuncture, light therapy, exercise, and mindfulness psychotherapies revealed promising results.  The authors concluded that more rigorous and larger studies are recommended.  Each CAM treatment must be evaluated separately in adequately powered controlled trials.  At this time, several CAM treatments appear promising and deserve further study.  The greatest risk of pursuing a CAM therapy is the possible delay of other well-established treatments.  Clinical, research, and educational initiatives designed to focus on CAM in psychiatry are clearly warranted due to the widespread use of CAM therapies.

In a review on bright-light therapy (BLT) for the treatment of mood disorders, Pail and colleagues (2011) stated that BLT is established as the treatment of choice for SAD/winter type.  In the last 2 decades, the use of BLT has expanded beyond SAD: there is preliminary evidence for its effectiveness in chronic depression, antepartum depression, pre-menstrual depression, bipolar depression and disturbances of the sleep-wake cycle.  However, the authors noted that data on the usefulness of BLT in non-seasonal depression are promising; further systematic studies are still needed.

Khan et al (2011) evaluated the current therapeutic options in the management of sleep disorders in visually impaired children to identify knowledge gaps and guide future research.  A search of primary literature was conducted using the bibliographic databases PubMed (1980 to August 2010), EMBASE (1990 to August 2010), Science Citation Index Expanded (1990 to August 2010), and CINHAL (1992 to August 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL).  Additional studies were identified through snowballing search techniques (manually by searching retrieved references and electronically by using citation-tracking software).  Search terms included behavioral treatment, children, circadian rhythm, hypnosedatives, intellectual disability, light therapy, melatonin, phototherapy, random allocation, randomized controlled trial (RCT), sleep disorder, and visual impairment.  Randomized and quasi-randomized clinical trials of therapeutic options (behavioral treatment, LT, melatonin, or hypnosedatives) used in participants aged 3 months to 18 years who had both a visual impairment and a sleep disorder were included.  Independent extraction of articles was performed by 2 authors using pre-defined data fields, including quality of the therapeutic options, based on the Strength of Recommendation Taxonomy evidence-rating system.  Two RCTs were retrieved for melatonin, with improved effect on sleep latency (p = 0.019 and p < 0.05, respectively).  However, separate analysis for visual impairment was not conducted.  No RCTs were retrieved for behavioral intervention, LT, or hypnosedatives.  Three studies using behavioral therapy (2 case reports and 1 case series) anecdotally showed improvement in sleep habit.  No improvement in sleep rhythm was observed with a case series applying LT as an intervention.  The authors concluded that children with visual impairment and sleep disorders are a heterogeneous patient group, making diagnosis and treatment difficult.  Randomized controlled trials on treatment options remain in their infancy, with a lack of evidence for appropriate therapeutic strategies.  Trials across a range of selected diagnoses need to be conducted with adequate sample populations to differentiate the effectiveness of 4 different treatment modalities (namely, behavioral therapy, LT, melatonin, and hypnosedatives) as agents for improving sleep.

Janas-Kozik et al (2011) evaluated the effect of short time (6 weeks) BLT on depressive symptoms in female patients with the restrictive type of anorexia nervosa (AN-R).  A total of 24 girls, aged 15 to 20 (mean of 17.4 +/- 1) years, diagnosed as AN-R, with concomitant depressive symptoms greater than or equal to 17 points on the 21-item Hamilton Depression Rating Scale (HDRS) were studied.  All girls received cognitive behavioral therapy.  Among them, 12 were randomly assigned to additional treatment with BLT for 6 weeks (10,000 lux, 30 mins daily).  Both groups did not differ on baseline demographic and clinical parameters.  The assessments of depression by means of HDRS and measuring of body mass index (BMI) were done weekly throughout the treatment.  Improvement of depression was significantly greater in the group receiving BLT, with a significant difference between groups in depression intensity after 5 and 6 weeks.  There was no difference in the increase of BMI between groups after 6 weeks, although such increase started earlier in patients treated with BLT.  The authors concluded that these findings may suggest that BLT could be an effective non-pharmacological modality for the treatment of depression in patients with AN-R.  Drawbacks of this study included: (i0 small sample size, and (ii) 6 weeks of treatment may be an insufficient duration to draw the conclusion about the effectiveness of BLT.  Well-designed studies with longer follow-up are needed validate these findings.

Poon and colleagues (2012) stated that many patients diagnosed with bipolar disorder (BD) respond incompletely or unsatisfactorily to available treatments.  Given the potentially devastating nature of this prevalent disorder, there is a pressing need to improve clinical care of such patients.  These researchers performed a literature review of the research findings related to treatment-resistant BD reported through February 2012.  Therapeutic trials for treatment-resistant bipolar mania are uncommon, and provided few promising leads other than the use of clozapine.  Far more pressing challenges are the depressive-dysthymic-dysphoric-mixed phases of BD and long-term prophylaxis.  Therapeutic trials for treatment-resistant bipolar depression have assessed anti-convulsants, modern anti-psychotics, glutamate [N-methyl-D-aspartate (NMDA)] antagonists, dopamine agonists, calcium-channel blockers, and thyroid hormones, as well as behavioral therapy, sleep deprivation, light therapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation, and deep brain stimulation -- all of which are promising but limited in effectiveness.  Several innovative pharmacological treatments (an anti-cholinesterase, a glutamine antagonist, a calcium-channel blocker, triiodothyronine, olanzapine and topiramate), ECT, and cognitive-behavior therapy have some support for long-term treatment of resistant BD patients, but most of trials of these treatments have been methodologically limited.  The authors concluded that most studies identified were small, involved supplementation of typically complex ongoing treatments, varied in controls, randomization, and blinding, usually involved brief follow-up, and lacked replication.  Moreover, they stated that clearer criteria for defining and predicting treatment resistance in BD are needed, as well as improved trial design with better controls, assessment of specific clinical subgroups, and longer follow-up.

Dauphinais et al (2012) stated that treatment of BD often results in patients taking several drugs in an attempt to alleviate residual depressive symptoms, which can lead to an accumulation of side effects.  New treatments for bipolar depression that do not increase the side effect burden are needed.  One non-pharmacological treatment with few side effects, BLT, has been shown to be an effective therapy for seasonal affective disorder, yet has not been extensively studied for other forms of depression.  In this study, a total of 44 adults with BD (depressed phase) were randomized to treatment with BLT, low-density or high-density negative ion generator for 8 weeks.  The primary measure of effectiveness was the Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement (SIGH-ADS).  Adverse events were assessed using the Young Mania Rating Scale (YMRS) and Systematic Assessment for Treatment Emergent effects (SAFTEE).  All outcome variables were statistically analyzed using a mixed model repeated measure analysis of variance (ANOVA).  The results showed no statistically significant differences between groups in any outcome measures at study end-point; adverse events, including switches into hypomania, were rare.  The authors concluded that further research is needed to determine the effectiveness of BLT in this population.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
96900
HCPCS codes covered if selection criteria are met:
A4634 Replacement bulb for therapeutic light box, tabletop model
E0203 Therapeutic lightbox, minimum 10,000 lux, table top model
ICD-9 codes not covered for indications listed in the CPB:
296.00 - 296.16, 296.40 - 296.89 Bipolar disorder [seasonal affective disorder]
296.30 - 296.36 Major depression disorder, recurrent episode [seasonal affective disorder]
ICD-9 codes not covered for indications listed in the CPB:
290 - 290.3 Dementias
294.10 - 294.11 Dementia in conditions classified elsewhere without behavioral disturbance or with behavioral disturbance
307.1 Anorexia nervosa
307.40 - 307.49 Specific disorders of sleep of nonorganic origin
327.00 - 327.8 Organic sleep disorders
368.00 - 368.9 Visual disturbances [for sleep disorders in visually impaired children]
625.4 Premenstrual tension syndromes [PMS] [PMDD]
648.40 - 648.44 Mental disorders of mother, complicating pregnancy, childbirth, or the puerperium [postnatal depression]
780.50 - 780.59 Sleep disturbances
Other ICD-9 codes related to the CPB:
296.20-296.36, 296.90 - 296.99 Affective psychoses
298.0 Depressive type psychosis
300.4 Dysthymic disorder
301.10-301.13 Affective personality disorder
311 Depressive disorder, not elsewhere classified


The above policy is based on the following references:
  1. Kaplan HI, Sadock BJ. Comprehensive Textbook of Psychiatry. Baltimore, MD: Williams & Wilkins; 1995.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994.
  3. Joffe RT, Moul DE, Lam RW, et al. Light visor treatment of seasonal affective disorder. Psych Res. 1993;46(1):29-39.
  4. Tam EM, Lam RW, Levitt AJ. Treatment of seasonal affective disorder: A review. Can J Psychiatry. 1995;40(8):457-466.
  5. Terman M, Amira L, Terman JS, et al. Predictors of response and nonresponse to light treatment for winter depression. Am J Psychiatry. 1996;153(11):1423-1429.
  6. Leibenluft E, Turner EH, Feldman-Naim S, et al. Light therapy in patients with rapid cycling bipolar disorder: Preliminary results. Psychopharmacol Bull. 1995;31(4):705-710.
  7. Pracka D. Phototherapy in the clinic. Postepy Hig Med Dosw. 1999;53(3):517-523.
  8. Mersch PP, Middendorp HM, Bouhuys AL, et al. Seasonal affective disorder and latitude: A review of the literature. J Affect Disord. 1999;53(1):35-48.
  9. Partonen T, Lonnqvist J. Seasonal affective disorder. Lancet. 1998;352(9137):1369-1374.
  10. Avery DH. A turning point for seasonal affective disorder and light therapy research? Arch Gen Psychiatry. 1998;55(1):863-864.
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  19. Lam RW, Tam EM, Shiah IS, et al. Effects of light therapy on suicidal ideation in patients with winter depression. J Clin Psychiatry. 2000;61(1):30-32.
  20. Koorengevel KM, Gordijn MC, Beersma DG, et al. Extraocular light therapy in winter depression: A double-blind placebo-controlled study. Biol Psychiatry. 2001;50(9):691-698.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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